Request For Exemption - State Of Michigan Page 3
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4MICHIGAN DEPARTMENT OF ATTORNEY GENERAL
REQUEST FOR EXEMPTION
Exemption
Required Documentation
Enter the name of the parent hospital:
12.
A hospital-based foundation or auxiliary that solicits
contributions solely for 1 or more licensed hospitals.
See instructions.
13.
An organization that does not intend to solicit and receive,
This exemption also applies if the organization or trust does not
solicit or receive any contributions.
and does not actually receive, contributions in excess of
$25,000.00 during any 12-month period.
Provide a copy of your latest IRS 990, 990-EZ, or 990-PF.
Do not include grants from governmental agencies or restricted grants from
(We do not accept Form 990-N.) If you have not prepared
foundations when calculating contributions. See instructions.
an IRS return, provide a financial statement or treasurer's
report. If you are a newly created organization in your first
Note - To qualify for this exemption:
·
fiscal period, you do not have to provide a financial
All fundraising functions must be conducted by persons,
statement at this time.
whether staff or contractors, who are not paid for their
services.
Provide a schedule of all governmental grants and restricted
·
The organization must make a financial statement of its
grants from foundations received during the year of your
activities of its most recent fiscal year available to its members
financial report.
and the public.
14.
A nonprofit corporation whose purpose is the owning and
operating of facilities for the aged and chronically ill that is
Provide proof of sole control by a religious or fraternal society.
under the sole control of a religious or fraternal society.
15.
An organization at least 50% of whose activities are licensed
Enter the name of the specific state licensing agency and your
by the Michigan Department of Health and Human Services to
license number:
serve children and families.
Section III
The following section applies only to the STCPA.
16.
An organization incorporated or organized in a state other
than Michigan that will never hold assets in Michigan,
including cash, savings accounts, investment accounts, land,
building, equipment, etc.
17.
Identify the specific United Way office:
An organization that receives operating funds from United
Way.
18.
An amateur theater, band, orchestra, chorale or dance
organization.
Forms to provide
Key:
(available at )
If you did not check a box:
CTS-01, Initial Solicitation Form.
If you checked a box in Section I, or
CTS-03, Request for Exemption form.
if you checked boxes in more than one section:
CTS-03, Request for Exemption form and
If you checked a box in Section II and did not check a box in
CTS-05, Registration and Inventory Forms for Corporations
Sections I or III:
and Unincorporated Associations.
If you checked a box in Section III and did not check a box in Sections I
CTS-03, Request for Exemption form and
or II:
CTS-01, Initial Solicitation Form.
You will be notified in writing after your request for exemption has
been reviewed and a determination has been made.
CERTIFICATION
I certify that I am an authorized represtentative of the organization and that to the best of my knowledge and belief the
information provided, including all accompanying documents, is true, correct, and complete. False statements are
prohibited by MCL 400.288(1)(u) and MCL 400.293(2)(c) and are punishable by civil and criminal penalties.
Type or print name (must be legible)
Title
Date
This is a public record, copies of which are sent, upon request, to any interested person.
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